ACIP has now recommended influenza vaccination for all children 6 months to 18 years of age. While many school-aged children will be vaccinated in the medical home, the large number of children for whom the vaccine is now recommended exceeds the capacity of many primary care settings. Schools have been recommended as potential sites for influenza vaccination, yet little is known about the feasibility, implementation requirements, costs, or effectiveness of school- based influenza vaccination (SIV) programs. This project will implement and rigorously evaluate the feasibility, acceptability, billing and reimbursement components, costs, cost-effectiveness, and overall effectiveness of an SIV program that targets diverse populations and different intensities of a recruitment advertising intervention. The Monroe County SIV will integrate five sets of activities: 1) SIV program implementation in 24 elementary schools;2) a randomized controlled trial (RCT) testing SIV vs. standard-of-care and an RCT of high- vs. low-intensity SIV;3) economic analyses regarding income generation and costs of SIV with extrapolation to the U.S.;4) associated quantitative studies that will shed light on implementation issues including vaccine refusal, parents'attitudes and beliefs regarding SIV, and teachers'perceptions of vaccination in participating and non-participating schools;and 5) qualitative studies examining attitudes and beliefs of various groups including parents, mass vaccinators, school personnel, and insurers. Key factors of strategic importance to this proposal include: the significance to the nation of results that will be generated by the proposed body of work, the approach that interweaves collaborative program implementation and carefully constructed evaluation;an innovative nesting of randomized controlled trials (RCT) testing both SIV vs. Standard-of-care and High-Intensity vs. Low-Intensity interventions;a team of investigators with one of the U.S.'s top records in immunization research including RCTs, economic studies and modeling, quantitative surveys, and qualitative research;and an environment that ensures success because of long-standing collaborations between the Monroe County Department of Public Health, a nursing organization experienced in mass vaccinations, the NYS Department of Health, academicians at the University of Rochester Medical Center, the local school districts, pediatric and family physician professional organizations, and health care insurers. PUBLIC HEALTH RELEVANCE: The relevance of this research to public health is that - just as ACIP has recommended influenza vaccination for all children 6 months to 18 years of age - the proposed Monroe County project would both implement a school-based influenza vaccination (SIV) program and study the program's costs and benefits (vaccine uptake) while examining billing and reimbursement from the perspective of a party capable of billing insurers for vaccination. The innovative nesting of randomized controlled trials testing both SIV vs. Standard-of-care and High-Intensity vs. Low- Intensity interventions is further strengthened by a carefully crafted set of economic studies and modeling, quantitative surveys, and qualitative research.